Asperger's Syndrome
The Boundaries between Asperger and Nonverbal Learning
Guidelines for Assessment and Diagnosis 
Research Participants Needed
OASIS
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CONDITION CENTERS
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Web Links:
Asperger's Association of New England - coalition of individuals with the syndrome, their families and friends and professional care takers.
AspergersMichigan.com - focuses on issues surrounding Asperger Syndrome and its treatment.
Asperger's Disorder Homepage- A complete overview of Aspergers.
Asperger Syndrome Australian Information Centre - An internet site for those involved with the caring of children with Aspergers Syndrome. The site features a message board, chat room and links to various AS ands autism related sites in Australia and overseas
ASD - Loads of links and other goodies on the ninemsn communities site
ASSN - Asperger Syndrome Support Network - Support site based in Victoria.
ASPEN - ASPerger syndrome Education Network (New Jersey)
Book in Hand - The bookshop for reference works, with a superb online catalogue and secure online ordering.
Kids with Asperger's Syndrome: A Challenge for Parents - feature article from the Mayo Clinic describing the condition, its symptoms and diagnosis, and coping.
Los Angeles Asperger's Syndrome Parent's Support Group - support group for parents of children (including adult children) with Asperger's Syndrome, high-functioning Autism, and Non-verbal Learning Disorder.
MAAP Services - providing information and advice to families of individuals with autism, Asperger's syndrome, and pervasive developmental disorder.
Parent Portal - Parent Portal - Information service designed especially for parents of children with developmental disability
Therapy Focus - Autism Services Profile, listing of services available in Western Australia
Tips on Asperger's Syndrome- Educational approaches for students with Aspergers.
WHO'S TO KNOW? Disclosing Asperger Syndrome
Yigoto - Asperger's Syndrome - information about the disease and its effects. Return to Top
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Written by Stephen M. Edelson, Ph.D.
Center for the Study of Autism, Salem, Oregon
Asperger's syndrome was first described by a German doctor, Hans Asperger,
in 1944 (one year after Leo Kanner's first paper on autism). In his paper,
Dr. Asperger discussed individuals who exhibited many idiosyncratic,
odd-like behaviors (see description below).
Often individuals with Asperger's syndrome have many of the behaviors listed
below:
Language
Lucid speech before age 4 years; grammar and vocabulary are usually very good speech is sometimes stilted and repetitive voice tends to be flat and emotionless
conversations revolve around self
Cognition
Obsessed with complex topics, such as patterns, weather, music, history,
etc.
often described as eccentric
I.Q.'s fall along the full spectrum, but many are in the above normal range
in verbal
ability and in the below average range in performance abilities.many have dyslexia, writing problems, and difficulty with mathematics
lack common senseconcrete thinking (versus abstract)
Behavior
Movements tend to be clumsy and awkward
odd forms of self-stimulatory behavior
sensory problems appear not to be as dramatic as those with other forms of
autism
socially aware but displays inappropriate reciprocal interaction
Researchers feel that Asperger's syndrome is probably hereditary in nature
because many families report having an "odd" relative or two. In addition,
depression and bipolar disorder are often reported in those with Asperger's
syndrome as well as in family members. At this time, there is no prescribed
treatment regimen for individuals with Asperger's syndrome. In adulthood,
many
lead productive lives, living independently, working effectively at a job
(many are
college professors, computer programmers, dentists), and raising a family.
Sometimes people assume everyone who has autism and is high-functioning has
Asperger's syndrome. However, it appears that there are several forms of
high-functioning autism, and Asperger's syndrome is one form.
The Autism Research Institute distributes an information packet on
Asperger's
Syndrome.
For more information visit: Asperger Research Institute
Check out these other links:
Autism and Instrumental Biocommunication:
Autism and Service Dogs Of America
Consider reading:
Songs of the Gorilla Nation by Dawn Prince-Hughes, Ph.D.
My Journey Through Autism; Harmony Books, 2004. ISBN:1400050588; 240 pages
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The Boundaries between Asperger and Nonverbal Learning Disability Syndromes
by Bonny Forrest, Ph.D
The purpose of this article is to review similarities and differences between Asperger (AS) and Nonverbal Learning Disability (NVLD) Syndromes. The existence of AS as a separate diagnostic entity from Autism remains controversial. Much
of this controversy stems from the presence of children who have social deficits characteristic of Autism but exhibit lesser degrees of language impairments, and from the use of the age of onset of language deficits to distinguish
between the two syndromes. Perhaps even more contestable is whether a distinction exists between AS and NVLD. The latter, which has not yet been recognized by the DSM-IV-TR as a diagnostic entity, has been most frequently defined in
the literature by a specific neuropsychological profile. This profile can be very similar to that of children with AS. The main difference between the two disorders, as they are most frequently defined clinically, is the absence in
children with NVLD of restricted interests or special skills. The diagnostic situation is further complicated, however, by the complex and still-changing definitions of the social deficits observed in NVLD.
Asperger Syndrome
Behavioral Consequences
Attempts have been made to distinguish children with AS on the basis of the functional aspects of their social impairments. Their social interactions have been described as lacking in empathy, exhibiting poor nonverbal communication
and use of speech, and being overly reliant on rote language abilities. These children are usually aware of their inability to connect to others (Volkmar and Klin, 2000). In addition, the child with AS tends to become an expert in a
specific area of interest (e.g., the weather or subway lines). Although one subgroup of the children with nonverbal disorders of learning described by Johnson and Myklebust (1967) exhibits social deficits, this group does not generally
exhibit restricted interests or special skills that would meet the criteria for diagnostic classification as AS.
Neuropsychological Profiles
Few studies have attempted to validate a neuropsychological profile of children with AS. The results of this handful of studies, although far from providing a definitive template, seem to suggest that individuals with AS have deficits
in fine and gross motor skills, visual motor integration, visual-spatial perception, nonverbal concept formation, and visual memory. Language skills are generally intact (Klin, Volkmar and Sparrow, 2000). This profile of
neuropsychological assets and deficits is very similar to the NVLD profile described by Rourke (1995), as discussed below.
Nonverbal Learning Disabilities
Behavioral Characteristics
Johnson and Myklebust (1967) were the first to posit the existence of discrete subtypes of nonverbal learning disorders, including one sub-group of children with nonverbal deficits who have deficiencies in social perception. They
defined social perception broadly as the inability of a child to interpret both the emotions expressed by another person and the perception of oneself in relation to the behavior of others. Such children cannot pretend, anticipate,
evaluate the significance of certain aspects of their environment, or comprehend the meaning of facial expressions and gestures or the subtleties of emotions. They further described the children with difficulties in social perception
as having average or above average abilities in language but difficulty using those language skills.
Neuropsychological Profiles
Byron Rourke’s (1995) recent research has focused primarily on the combination of neuropsychological assets and deficits that produces as a byproduct the poor social relatedness that Johnson and Myklebust (1967) described as characteristic of only one group of children with NVLD. Rourke described the neuropsychological deficits in NVLD more specifically in terms of primary, secondary, and tertiary deficits. The children he studied had primary deficits in tactile perception, visual perception, complex psychomotor activities and the ability to process novel material. Secondary deficits (secondary because they were related to the basic deficits) included difficulties in tactile attention, visual attention and exploratory behavior. Tertiary deficits included tactile memory, visual memory, concept formation and problem solving. According to Rourke (1995), when these neuropsychological deficits interact with assets in auditory perception, simple motor skills and the ability to process rote material, socioemotional or adaptational deficits result. Children with NVLD as described by Rourke (1995) often exhibit extreme difficulty in processing new or complex social situations and interpreting facial expressions. In novel situations, they rely on repetitious or rote behaviors, because they excel in these skills. Their interactions with other children are stereotypical and lacking in reciprocity (Rourke and Tsatsanis, 2000). Children encompassed in Rourke’s (1995) description may manifest these symptoms from birth or as a result of neuropsychological injury or disease.
The young boy examined in the following case report provides a graphic illustration of the difficulties presented when attempting to diagnose a child who exhibits some but not all of the characteristics associated with both AS and NVLD.
Case Report
M is an eight-year, eight-month-old right-handed male. He has worn glasses since the age of 9 ½ months. M was slow to crawl (11 ½ months) but walked independently at 14 months. His parents were also concerned that his social skills lagged behind his peers. M frequently observed other children but was hesitant to engage them in play. School personnel corroborated these concerns as early as preschool.
M had three comprehensive assessments, followed by additional testing as part of a research study.
At the time of the first assessment at four years and ten months, later motor milestones, such as undressing, dressing, and copying shapes, were beginning to emerge. Language skills were described as quite good. His verbal abilities were assessed at the 99th percentile. M’s performance revealed deficits, however, in gross and fine motor abilities and sensory integration.
M underwent a neuropsychological evaluation at the age of 5 years, 4 months. At that evaluation, numbers and their applications (e.g., number of cars in a train) intrigued M. All verbal skills during this second evaluation were Average to High Average for his age. Nonverbal skills, in contrast, ranged from 2 ½- to 4-year-old levels. A diagnosis of PDD-NOS was ruled out during that assessment because of his language skills. Asperger Syndrome was also ruled out because of his lack of restricted repetitive and stereotyped patterns of behaviors or interests. M was given a formal diagnosis at that time of NVLD. A supplemental assessment by the school approximately 6 months later at 5 years, 10 months showed math abilities at the 56th percentile.
Finally, at the age of 6 years, 11 months, M underwent a second neuropsychological evaluation. His performance on the WISC-III is set forth below. Additional testing revealed above average verbal and significantly impaired nonverbal skills. Math reasoning abilities on the Wechsler Individual Achievement Test were at the 27th percentile with a standard score of 91. He also had poor vocal tone, prosody and awareness of the pragmatic uses of language. M’s social relations were better than when he was younger; however, he was reported to have no best friend. A diagnosis of Learning Disorder, Not Otherwise Specified was given and the prior diagnosis of NVLD was confirmed.
Overall Intellectual Function-WISC-III Scaled and Standard Scores
Information 14 Picture Completion 08 VC 116
Similarities 10 Coding 02 PO 75
Arithmetic 07 Picture Arrangement 05 FD 93
Vocabulary 16 Block Design 01 PS 75
Comprehension 11 Object Assembly 08 VIQ 110
Digit Span10 Symbol Search 08 PIQ 69
FSIQ 88
Additional testing completed as part of a research study resulted in the following scores:
Achievement-standard scores.
WRAT-3 Key-Math Revised
Reading 85 Concepts 99
Spelling 91 Operations 88
Arithmetic 71 Applications 100
Executive Functions-Z, scaled, T or percentage scores as reported by instrument.
Trails A -.9
Trails B -.32
NEPSY-Tower 10
NEPSY-Auditory Attention 10
NEPSY-Visual Attention 06
NEPSY-Core Domain Score 90
NEPSY-Design Fluency 09
NEPSY-Knock and Tap <2%
Behavior Rating Inventory of Executive Function- Parent Form
Elevated T scores in Behavioral Regulation, Initiation, Planning and Organization and Working Memory
Language-scaled scores.
NEPSY-Speeded Naming 08
NEPSY-Comprehension of Instructions 09
NEPSY-Verbal Fluency 15
Sensorimotor-scaled or z scores and percentages as appropriate to the instrument.
NEPSY-Visiomotor Precision 04
NEPSY-Finger Discrimination
Dominate >75%
Nondominate >75%
NEPSY-Imitating Hand Positions 01
Grooved Pegboard Test
Right -10
Left -5.8
Visual-spatial-scaled, standard or percentage scores.
VMI 87
VMI-Visual 109
VMI-Motor 72
NEPSY-Arrows 06
NEPSY-Block Construction 08
NEPSY-Route Finding 10-25%
Memory and Learning-scaled scores.
NEPSY-Memory for Names 06
NEPSY-Sentence Repetition 11
NEPSY-List Learning 09
NEPSY-Memory for Faces 12
Social and Emotional Functioning-z scores.
Child and Adolescent Social Perception Measure
Total Emotion Score -.50
Total Nonverbal Cue Score -2.25
Personality Inventory for Children
Elevated levels for Intellectual Screening and Psychosis
Discussion
Although M fits the general neuropsychological profile for both AS and NVLD, he does not have some of the behavioral characteristics required for a diagnosis of AS: he lacks ascribed interests or special skills in the presence of nonverbal cognitive deficits. Although M’s interest in numbers at one point was considered a possible precursor to a restricted interest that might be indicative of AS, by the age of 8 that interest was not considered clinically significant. When three neuropsychologists at separate major Northeastern University Hospitals diagnosed M, each ruled out AS because of M’s behavioral characteristics and relied on the neuropsychological profile and the deficits in social skills to assign an NVLD diagnosis. A diagnosis of Autism was never discussed.
In their reports, however, each alluded to the difficulties of diagnosing M with NVLD because he did not exhibit all of its characteristics. These difficulties would have been even more pronounced if these clinicians had attempted to apply more recent descriptions of NVLD by Rourke (2000a) or his proposed ICD-10 criteria.
Consistent with Rourke’s (1995) neuropsychological descriptions of NVLD, M’s verbal skills were above average, his mechanical math score on the WRAT-3 was at least 8 standard points lower than his reading score, and he had difficulties with graphomotor activities, tone and prosody. But M does not exhibit some of the other tertiary and secondary neuropsychological deficits described by Rourke (1995). In addition, a number of M’s strengths are inconsistent with more recent descriptions of the developmental progression of NVLD (Rourke, 2000a). Finally, M’s social abilities are inconsistent with those described in Rourke’s (2000a) proposed ICD-10 criteria.
As to M’s other neuropsychological abilities, his visual memory and visual motor integration abilities are relatively intact and are therefore inconsistent with the secondary deficits described by Rourke (1995). (These abilities may also be inconsistent with a diagnosis of AS.) His oral-motor praxis abilities were also average. Finally, although M had mechanical arithmetic difficulties on the WRAT-3, these difficulties did not result in deficits in mathematics in general as described by Rourke (1995). The difficulties are consistent, however, with descriptions by Badian (1983) of children with poor social skills and anarithmetria.
Rourke’s recent developmental definitions of NVLD suggest that most children with NVLD manifest language deficits at an early age. M did not. This age-of-onset criterion, which is not present in earlier descriptions of NVLD, makes NVLD appear more similar to Autism. See http://www.nldontheweb.org/Byron_Rourke_QA15.htm.
Rourke has also proposed ICD-10 criteria for NVLD that include behavioral characteristics of a distorted sense of time and extreme social impairment. See http://www.nldontheweb.org/Byron_Rourke_QA15.htm and http://www.nldontheweb.org/Byron_Rourke_QA18.htm. How the social deficits in these criteria are qualitatively different from those observed in Autism or AS is unclear. M did not have a distorted sense of time (e.g., when asked how long it took to tie his shoes, M replied, “For most kids they can do it in about 20 seconds, me it takes about two minutes.”) M’s social deficits could also not be characterized as extreme. M did have difficulty adapting to new situations, engaging in reciprocal conversations and judging personal space distances. On the Personality Inventory for Children (Wirt et al., 1977), however, he did not have elevated levels of depression or withdrawal. His mood lability resulted in a clinically significant elevation of psychosis. M could name some of the emotions exhibited in the Child and Adolescent Social Perception Measure (Magill-Evans et al., 1995), although he could not tell you how he knew what children in the scenes were feeling. M’s subtle social deficits seem to be more like those of the subgroup of children described by Johnson and Myklebust (1967) than those described by Rourke (2000b).
Future studies that attempt to distinguish AS and NVLD might investigate any differences in social abilities between the two groups (Volkmar and Klin, 1998). M’s social abilities were poor but they also seemed less compromised than those typically observed in AS. Rourke and Tsatsanis (2000) have stated that the psychosocial deficits experienced by children who exhibit NVLD “are viewed as the direct result of the interaction” of the neuropsychological assets and deficits (p. 237). The nonverbal cognitive profile in AS and NVLD has also been described, however, as limiting a child’s ability to make full use of social cues because it affects their ability to process nonverbal stimuli in various modalities. (Volkmar and Klin, 1998). Still others have said that children with the NVLD profile may or may not exhibit social deficits. (Pennington, 1991). Future research should provide better descriptions of the nature and extent of the social abilities in children with AS and NVLD. It would also appear that M might not meet the criteria for PDD-NOS specified in the practice parameters by the American Academy of Child and Adolescent Psychiatry and the DSM-IV-TR because his social deficit is not severe and pervasive. See http://www.guidelines.gov/VIEWS/summary.asp?guideline=001367.
We are left to speculate as to whether the discrepancies in M’s verbal and performance scores were relied on too heavily in indicating a diagnosis of NVLD. Given M’s history of poor motor development and current test performance, it appears that most of his cognitive difficulties stem from his motor dyspraxia. His social difficulties are more appropriately addressed, however, by an NVLD diagnosis. In the absence of social disability criteria independent of Autism, AS or NVLD, an NVLD diagnosis is frequently used to fill the void and obtain the necessary services.
In sum, M meets some but not all of the proposed criteria for NVLD. How many he meets depends on the description of NVLD one uses. As this article has indicated, the changing and sometimes conflicting protocols and descriptions of NVLD complicate the diagnostic process.
For example, M meets at least five of the eight current criteria for NVLD or “probable NVLD” as described in Rourke’s protocol for children slightly older (nine) than M. See www.nldontheweb.org/Byron_Rourke_QA18.htm. That protocol is separate from and less comprehensive than Rourke’s qualitative descriptions at www.nldontheweb.org/Byron_Rourke_QA2.htm. The neuropsychological diagnosis of NVLD is often complicated by the fact that this protocol requires deficits on the Tactile Performance Test and the Target Test, which are infrequently used in assessments.
Additionally, M meets approximately five of the ten “characteristics” described in children under the age of six, and seven of eight of the characteristics described in children seven and above. See http://www.nldontheweb.org/Byron_Rourke_QA15.htm. Finally, he meets approximately 6 of 10 of the ICD-10 criteria proposed by Rourke. See http://www.nldontheweb.org/Byron_Rourke_QA15.htm. Qualitatively, M is more accurately captured by the descriptions of children with social deficits and nonverbal disorders of learning provided by Johnson and Myklebust (1967) and Badian (1983).
Conclusions
Although the neuropsychological descriptions of children with AS and NVLD are similar, behavioral criteria may be used to distinguish the two disorders. The diagnosis is complicated, however, by three factors.
First, at present, most clinicians see NVLD as a neuropsychological rather than behavioral diagnosis.
Second, the exact nature and causes of the behavioral and social deficits associated with NVLD are poorly understood. In fact, it is not clear that all children with NVLD have these deficits. According to Johnson and Myklebust (1967), children with nonverbal deficits of learning such as visual-spatial difficulties may or may not experience social deficits. Rourke’s (1995) criteria do not seem to require a behavioral or social deficit, and, in the vast majority of his work, he discusses social deficits primarily as a consequence of neuropsychological problems. Rourke’s (2000a) more recent descriptions, however, seem to include a requirement of extreme social deficits for a diagnosis of NVLD.
Third, different definitions of NVLD carry with them different conclusions about the ability to distinguish it from AS. Rourke and Tsatsanis (2000) have noted that the NVLD description applies to children with AS. Rourke’s proposed ICD-10 criteria would seem to imply, however, that NVLD is a separate diagnostic entity from AS.
Given the present state of research into and definitions of AS and NVLD, AS and NVLD can most usefully be seen clinically -- as M’s diagnostic history indicates -- as behaviorally distinct with neuropsychological similarities.
References
Badian, N. A. (1983). Dyscalculia and nonverbal disorders of learning. In H. R. Myklebust (Ed.). Progress in learning disabilities, Vol. 5 (pp. 235-264). New York: Grune & Stratton.
Johnson, D. & Myklebust, H. (1967). Learning disabilities: Educational principles and practices. New York: Grune & Stratton.
Klin, A, Volkmar, F.R., and Sparrow, S.S. (2000). Asperger Syndrome. New York: The Guilford Press.
Klin, A, Volkmar, F.R., Sparrow, S.S., Cicchetti, D.V. & Rourke, B.P. (1995). Validity and neuropsychological characterization of Asperger syndrome: Convergence with NVLD syndrome. J. Child Psychology and Psychiatry, 36 (7) 1127-1140.
Magill-Evans, J., Koning, C., Cameron-Sadava, A. & Manyk, K. (1995). The Child and Adolescent Social Perception Measure. Journal of Nonverbal Behavior, 19 (3), 151-169.
Pennington, B. (1991). Diagnosing learning disorders. New York: Guilford Press.
Rourke, B. (2000a). Webpage at http://www.nldontheweb.org/Byron_Rourke_QA15.htm located within: http://www.nldontheweb.org/Byron_Rourke_hompage.htm.
Rourke, B. (2000b). Conference on nonverbal learning disabilities. Speech and materials presented in New Haven, CT.
Rourke, B. (Ed.) (1995). Syndrome of Nonverbal Learning Disabilities: Neurodevelopmental Manifestations. New York: The Guilford Press.
Rourke, B. (1987). Syndrome of nonverbal learning disabilities: The final common pathway of white-matter disease/dysfunction? Clinical Neuropsychologist, 1(3), 209-234.
Rourke, B.P. & Tsatsanis, K.D. (2000). Nonverbal learning disabilities and Asperger Syndrome. In Klin, A., Volkmar, F. and Sparrow, S. (Eds.) Asperger Syndrome (pp. 231-253). New York: The Guilford Press.
Volkmar, F.R. & Klin, A. (1998). Asperger Syndrome and nonverbal learning disabilities. In Schopler, E. and Mesibov, G. B. (Eds.) Asperger Syndrome or High Functioning Autism? Current issues in autism (pp. 107-121). New York: Plenum Press.
Volkmar, F.R. & Klin, A. (2000). Diagnostic Issues. In Klin, A., Volkmar, F. and Sparrow, S. (Eds.) Asperger Syndrome (pp. 25-71). New York: The Guilford Press.
Wirt, R., Lachar, D., Klinedinst, J. and Seat, P. (1977). Personality inventory for children. Los Angeles: Western Psychological Corporation.
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Guidelines for Assessment and Diagnosis
by Ami Klin, Ph.D., and Fred R. Volkmar, M.D.
Yale Child Study Center, New Haven, Connecticut
Published by the Learning Disabilities Association of America, June 1995
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Introduction
Background
Related Diagnostic Concepts
Categorical Definition and Clinical Description
Onset Criteria
Qualitative Impairments in Reciprocal Social Interaction
Qualitative Impairments in Communication
Restrictive, Repetitive, and Stereotyped Patterns of
Behavior, Interests, and Activities
Motor Clumsiness
Assessment
History
Psychological Assessment
Communication Assessment
Psychiatric Examination
Treatment and Intervention
Securing Services
Learning
Adaptive Functioning
Maladaptive Behaviors
Social and Communication Skills
Vocational Training
Self-Support
Pharmacotherapy
New Developments in the Field
Introduction
Asperger Syndrome (AS) is a severe developmental disorder characterized by major difficulties in social interaction, and restricted and unusual patterns of interest and behavior. There are many similarities with autism without mental
retardation (or "Higher Functioning Autism"), and the issue of whether Asperger syndrome and Higher Functioning Autism are different conditions is not resolved. To some extent, the answer to this question depends on the way clinicians
and researcher make use of this diagnostic concept, since until recently there was no "official" definition of Asperger syndrome. The lack of a consensual definition led to a great deal of confusion as researchers could not interpret
other researchers' findings, clinicians felt free to use the label based on their own interpretations or misinterpretations of what Asperger syndrome "really" meant, and parents were often faced with a diagnosis that nobody appeared to
understand very well, and worse still, nobody appeared to know what to do about it. School districts are not aware of the condition, insurance carriers could not reimburse services provided on the basis of this "unofficial" diagnosis,
and there was no published information providing parents and clinicians alike with guidelines on the meaning and implications of Asperger syndrome, including what should the diagnostic evaluation consist of and what forms of treatment
and interventions were warranted.
This situation has changed somewhat since Asperger syndrome was made "official" in DSM-IV (APA, 1994), following a large international field trial involving over a thousand children and adolescents with autism and related disorders (Volkmar
et al., 1994). The field trials revealed some evidence justifying the inclusion of Asperger syndrome as a diagnostic category different from autism, under the overarching class of Pervasive Developmental Disorders. More importantly, it
established a consensual definition for the disorder which should serve as the frame of reference for all those using the diagnosis. However, the problems are far from over. Despite some new research leads, knowledge on Asperger
syndrome is still very limited. For example, we don't really know how common it is, or the male/female ratio, or to what extent there may be genetic links increasing the likelihood of finding similar conditions in family members.
Clearly, the work on Asperger syndrome, in regard to scientific research as well as in regard to service provision, is only beginning. Parents are urged to use a great deal of caution and to adopt a critical approach toward information
given to them. Ultimately, the diagnostic label - any label, does not summarize a person, and there is a need to consider the individual's strengths and weaknesses, and to provide individualized intervention that will meet those
(adequately assessed and monitored) needs. That notwithstanding, we are left with the question of what is the nature of this puzzling social learning disability, how many people does it affect, and what can we do to help those affected
by it. The following guidelines summarize some of the information currently available on those questions.
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Background
Autism is the most widely recognized pervasive developmental disorder (PDD). Other diagnostic concepts with features somewhat similar to autism have been less intensively studied, and their validity, apart from autism, is more
controversial. One of these conditions, termed Asperger syndrome (AS) was originally described by Hans Asperger (1944, see Frith's translation, 1991), who provided an account of a number of cases whose clinical features resembled
Kanner's (1943) description of autism (e.g., problems with social interaction and communication, and circumscribed and idiosyncratic patterns of interest). However, Asperger's description differed from Kanner's in that speech was less
commonly delayed, motor deficits were more common, the onset appeared to be somewhat later, and all the initial cases occurred only in boys. Asperger also suggested that similar problems could be observed in family members,
particularly fathers.
This syndrome was essentially unknown in the English literature for many years. An influential review and series of case reports by Lorna Wing (1981) increased interest in the condition, and since then both the usage of the term in
clinical practice and number of case reports and research studies have been steadily increasing. The commonly described clinical features of the syndrome include:
paucity of empathy;
naive, inappropriate, one-sided social interaction, little ability to form friendships and consequent social isolation;
pedantic and monotonic speech;
poor nonverbal communication;
intense absorption in circumscribed topics such as the weather, facts about TV stations, railway tables or maps, which are learned in rote fashion and reflect poor understanding, conveying the impression of eccentricity; and
clumsy and ill-coordinated movements and odd posture.
Although Asperger originally reported the condition only in boys, reports of girls with the syndrome have now appeared. Nevertheless, boys are significantly more likely to be affected. Although most children with the condition function
in the normal range of intelligence, some have been reported to be mildly retarded. The apparent onset of the condition, or at least its recognition, is probably somewhat later than autism; this may reflect the more preserved language
and cognitive abilities. It tends to be highly stable, and the higher intellectual skills observed suggest a better long-term outcome than is typically observed in autism.
Related Diagnostic Concepts
Several similar diagnostic concepts originating from adult psychiatry, neuropsychology, neurology, and other disciplines share, to a great degree, the phenomenological aspects of AS. For example, Wolff and colleagues described a group
of individuals with an abnormal pattern of behavior characterized by social isolation, rigidity of thought and habits, and an unusual style of communication. This condition was named schizoid personality disorder in childhood.
Unfortunately, a developmental account of this concept was not provided, making it difficult to ascertain the extent to which the individuals described may have also exhibited autistic-like symptomatology early on in life. More
generally, the understanding of AS as an unchanging personality trait fails to fully appreciate the developmental aspects of the disorder which may prove to be of great importance for differential diagnosis.
In neuropsychology, a great deal of research has been devoted to Rourke's (1989) concept of Nonverbal Learning Disabilities syndrome (NLD). The main contribution of this line of research has been the attempt to delineate the
implications for the child's social and emotional development of a unique profile of neuropsychological assets and deficits that appears to have a deleterious impact on the person's capacity for socialization as well as on the person's
interactive and communicative styles. The neuropsychological characteristics of individuals with the NLD profile include deficits in tactile perception, psychomotor coordination, visual-spatial organization, nonverbal problem-solving,
and appreciation of incongruities and humor. NLD individuals also exhibit well developed rote verbal capacities and verbal memory skills, difficulty in adapting to novel and complex situations, and over reliance on rote behaviors in
such situations, relative deficits in mechanical arithmetic as compared to proficiencies in single word reading, poor pragmatics and prosody in speech, and significant deficits in social perception, social judgment, and social
interaction skills. There are marked deficits in the appreciation of subtle and even fairly obvious nonverbal aspects of communication, that often result in other person's social disdain and rejection. As a result, NLD individuals show
a marked tendency toward social withdrawal and are at risk for development of serious mood disorders.
Many of the clinical features clustered together in NLD have also been described in the neurological literature as a form of Developmental Learning Disability of the Right Hemisphere (Denckla, 1983; Voeller, 1986). Children presenting
with this condition have also been shown to exhibit profound disturbances in interpretation and expression of affect and other basic interpersonal skills. Finally, an additional term researched in the literature, semantic-pragmatic
disorder (Bishop, 1989), has also captured aspects of NLD and AS.
It is currently unclear whether these concepts describe different entities or, more probably, provide different perspectives on a heterogeneous, yet overlapping, group of individuals sharing at least some common aspects. An important
goal of current research is to seek a convergence between the various discipline-specific accounts in order to make use of different methodologies in the effort to validate the behaviorally defined concept of AS. However, in order to
enhance comparability of studies, it is of great importance to establish consensual and stringent guidelines for the diagnosis of AS, particularly in regard to its similarities with related conditions.
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Categorical Definition and Clinical Description
As defined in DSM-IV (the most recent Diagnostic and Statistical Manual of the American Psychiatric Association, 1994), the tentative criteria for AS follow the same format, and in fact overlap to some degree, the criteria for autism.
The required symptomatology is clustered in terms of onset, social and emotional, and "restricted interests" criteria, with the addition of two common but not necessary characteristics involving motor deficits and isolated special
skills, respectively. A final criterion involves the necessary exclusion of other conditions, most importantly autism or a sub threshold (or "autistic-like") form of autism (Pervasive Developmental Disorder - Not Otherwise Specified).
Interestingly, the DSM-IV definition of AS is offered having autism as its point of reference; hence some of the criteria actually involve the absence of abnormalities in some areas of functioning that are affected in autism. The
following table summarizes the DSM-IV definition of AS:
Qualitative impairment in social interaction, as manifested by at least two of the following:
Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
Failure to develop peer relationships appropriate to developmental level
A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people
Lack of social or emotional reciprocity
Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
Apparently inflexible adherence to specific, nonfunctional routines or rituals
Stereotyped and repetitive motor mannerisms
Persistent preoccupation with parts of objects
The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning
There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years)
There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood
Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.
Onset criteria
In DSM-IV, the individual's history must show "a lack of any clinically significant general delay" in language acquisition, cognitive development and adaptive behavior (other than in social interaction). This contrasts with typical
developmental accounts of autistic children who show marked deficits and deviance in these areas prior to the age of 3 years.
Although the onset criterion is in agreement with Asperger's account, Wing (1981) noted the presence of deficits in the use of language for communication, if not in more specific language skills, in some of her case studies. It is
currently uncertain whether the lack of delays in the prescribed areas is a differential factor between AS and autism or, alternatively, a simple reflection of the higher developmental level associated with the usage of the term AS.
Other common descriptions of the early development of individuals with AS include a certain precociousness in learning to talk ("he talked before he could walk"), a fascination with letters and numbers -- in fact, the young child may
even be able to decode words although with little or no understanding ("hyperlexia") -- and the establishment of attachment patterns to family members but inappropriate approaches to peers and other persons, rather than withdrawal or
aloofness as in autism (e.g., the child may attempt to initiate contact with other children by hugging them or screaming at them and then puzzle at their responses). Again, these behaviors are not uncommonly described for
higher-functioning autistic children as well, albeit much more infrequently.
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Qualitative Impairments in Reciprocal Social Interaction
Although the social criteria for AS and autism are identical, the former condition usually involves fewer symptoms and has a generally different presentation than does the latter. Individuals with AS are often socially isolated but are
not unaware of the presence of others, even though their approaches may be inappropriate and peculiar. For example, they may engage the interlocutor, usually an adult, in one-sided conversation characterized by long-winded, pedantic
speech, about a favorite and often unusual and narrow topic. Also, although individuals with AS are often self-described "loners", they often express a great interest in making friendships and meeting people. These wishes are
invariably thwarted by their awkward approaches and insensitivity to other person's feelings, intentions, and nonliteral and implied communications (e.g., signs of boredom, haste to leave, and need for privacy). Chronically frustrated
by their repeated failures to engage others and make friendships, some of these individuals develop symptoms of depression that may require treatment, including medication.
In regard to the emotional aspects of social transactions, individuals with AS may react inappropriately to, or fail to interpret the valence of, the context of the affective interaction, often conveying a sense of insensitivity,
formality, or disregard to the other person's emotional expressions. That notwithstanding, they may be able to describe correctly, in a cognitive and often formalistic fashion, other people's emotions, expected intentions and social
conventions, but are unable to act upon this knowledge in an intuitive and spontaneous fashion, thus losing the tempo of the interaction. Such poor intuition and lack of spontaneous adaptation are accompanied by marked reliance on
formalistic rules of behavior and rigid social conventions. This presentation is largely responsible for the impression of social naivete and behavioral rigidity that is so forcefully conveyed by these individuals.
As with the majority of the behavioral aspects used to describe AS, at least some of these characteristics are also exhibited by individuals with higher-functioning autism, though, again, probably to a lesser extent. More typically,
autistic persons are withdrawn and may seem to be unaware of, and disinterested in, other persons. Individuals with AS, on the other hand, are often keen, sometimes painfully so, to relate to others, but lack the skills to successfully
engage them.
Qualitative Impairments in Communication
In contrast to autism, there are no symptoms in this area of functioning In the definition of AS. Although significant abnormalities of speech are not typical of AS, there are at least three aspects of these individuals' communication
skills which are of clinical interest. First, though inflection and intonation may not be as rigid and monotonic as in autism, speech may be marked by poor prosody. For example, there may a constricted range of intonation patterns that
is used with little regard to the communicative functioning of the utterance (assertions of fact, humorous remarks, etc.). Second, speech may often be tangential and circumstantial, conveying a sense of looseness of associations and
incoherence. Even though in some cases this symptom may be an indicator of a possible thought disorder, it is often the case that the lack of coherence and reciprocity in speech is a result of the one-sided, egocentric conversational
style (e.g., unrelenting monologues about the names, codes, and attributes of innumerable TV stations in the country), failure to provide the background for comments and to clearly demarcate changes in topic, and failure to suppress
the Vocal output accompanying internal thoughts.
The third aspect typifying the communication patterns of individuals with AS concerns the marked verbosity observed, which some authors see as one of the most prominent differential features of the disorder. The child or adult may talk
incessantly, usually about their favorite subject, often in complete disregard to whether the listener might be interested, engaged, or attempting to interject a comment, or change the subject of conversation. Despite such long-winded
monologues, the individual may never come to a point or conclusion. Attempts by the interlocutor to elaborate on issues of content or logic, or to shift the interchange to related topics, are often unsuccessful.
Despite the possibility that all of these symptoms may be accounted for in terms of significant deficits in pragmatics skills and/or lack of insight into, and awareness of, other people's expectations, the challenge remains to
understand this phenomenon developmentally as strategies of social adaptation.
Restrictive, Repetitive, and Stereotyped Patterns of Behavior, Interests, and Activities
Although in the DSM-IV definition the criteria for AS and autism are identical, requiring the presence of at least one of the symptoms in the list provided (see table above), it appears that the most commonly observed symptom in this
cluster refers to an encompassing preoccupation with restricted patterns of interest. In contrast to autism, where other symptoms in this area may be very pronounced, individuals with AS are not commonly reported to exhibit them with
the exception of the all-absorbing preoccupation with an unusual and circumscribed topic, about which vast amounts of factual knowledge are acquired and all too readily demonstrated at the first opportunity in social interaction.
although the actual topic may change from time to time (e.g., every year or two years), it may dominate the content of social interchange as well as the activities of individuals with AS, often immersing the whole family in the subject
for long periods of time. Even though this symptom may not be easily recognized in childhood (because strong interests in dinosaurs or fashionable fictional characters are so ubiquitous among young children), it may become more salient
later on as interests shift to unusual and narrow topics. This behavior is peculiar in the sense that often times extraordinary amounts of factual information are learned about very circumscribed topics (e.g., snakes, names of stars,
maps, TV guides, or railway schedules).
Motor Clumsiness
In addition to the required criteria specified above, an additional symptom is given as an associated feature though not a required criterion for the diagnosis of AS, namely delayed motor milestones and presence of "motor clumsiness".
Individuals with AS may have a history of delayed acquisition of motor skills such as pedaling a bike, catching a ball, opening jars, climbing "monkey-bars", and so on. They are often visibly awkward, exhibiting rigid gait patterns,
odd posture, poor manipulative skills, and significant deficits in visual-motor coordination. Although this presentation contrasts with the pattern of motor development in autistic children, for whom the area of motor skills is often a
relative strength, it is similar in some respects to what is observed in older autistic individuals. Nevertheless, the commonality in later life may result from different underlying factors, for example, psychomotor deficits in the
case of AS, and poor body image and sense of self in the case of autism. This highlight the importance of describing this symptom in developmental terms.
Assessment
AS, like other pervasive developmental disorders (PDDs), involves delays and deviant patterns of behavior in multiple areas of functioning, that often require the input of professionals with different areas of expertise, particularly
overall developmental functioning, neuropsychological features, and behavioral status. Hence the clinical assessment of individuals with this disorder is most effectively conducted by an experienced interdisciplinary team.
A few principles should be made explicit prior to a discussion of the various areas of assessment. First, given the complexity of the condition, importance of developmental history, and common difficulties in securing adequate services
for children and individuals with AS, it is very important that parents are encouraged to observe and participate in the evaluation. This guideline helps to demystify assessment procedures, avails the parents of shared observations
that can then be clarified by the clinician, and fosters parental understanding of the child's condition. All of these can then help the parents evaluate the programs of intervention offered in their community.
Second, evaluation findings should be translated into a single coherent view of the child: easily understood, detailed, concrete, and realistic recommendations should be provided. When writing their reports, professionals should strive
to express the implications of their findings to the patient's day-to-day adaptation, learning, and vocational training.
Third, the lack of awareness of many professionals and officials of the disorder, its features, and associated disabilities often necessitates direct and continuous contact on the part of the evaluators with the various professionals
securing and implementing the recommended interventions. This is particularly important in the case of AS, as most of these individuals have average levels of Full Scale IQ, and are often not thought of as in need for special
programming. Conversely, as AS becomes a more well-known diagnostic label, there is reason to believe that it is becoming a fashionable concept used in an often unwarranted fashion by practitioners who intend to convey only that their
client is currently experiencing difficulties in social interaction and in peer relationships. The disorder is meant as a serious and debilitating developmental syndrome impairing the person's capacity for socialization and not a
transient or mild condition. Therefore, parents should be briefed about the present unsatisfactory state of knowledge about AS and the common confusions of use and abuse of the disorder currently prevailing in the mental health
community. Ample opportunity should be given to clarify misconceptions and establish a consensus about the patient's abilities and disabilities, which should not be simply assumed under the use of the diagnostic label.
In the majority of cases, a comprehensive assessment will involve the following components: history, psychological assessment, communication and psychiatric assessments, further consultation if needed, parental conferences, and
recommendations.
History
A careful history should be obtained, including information related to pregnancy and neonatal period, early development and characteristics of development, and medical and family history. A review of previous records including previous
evaluations should be performed and the information incorporated and results compared in order to obtain a sense of course of development. Additionally, several other specific areas should be directly examined because of their
importance in the diagnosis of AS. These include a careful history of onset/recognition of the problems, development of motor skills, language patterns, and areas of special interest (e.g., favorite occupations, unusual skills,
collections). Particular emphasis should be placed on social development, including past and present problems in social interaction, patterns of attachment of family members, development of friendships, self-concept, emotional
development, and mood presentation.
Psychological Assessment
This component aims at establishing the overall level of intellectual functioning, profiles of strengths and weaknesses, and style of learning. The specific areas to be examined and measured include neuropsychological functioning
(e.g., motor and psychomotor skills, memory, executive functions, problem-solving, concept formation, visual-perceptual skills), adaptive functioning (degree of self-sufficiency in real-life situations), academic achievement
(performance in school-like subjects), and personality assessment (e.g., common preoccupations, compensatory strategies of adaptation, mood presentation).
The neuropsychological assessment of individuals with AS involves certain procedures of specific interest to this population. Whether or not a Verbal-Performance IQ discrepancy is obtained in intelligence testing, it is advisable to
conduct a fairly comprehensive neuropsychological assessment including measures of motor skills (coordination of the large muscles as well as manipulative skills and visual-motor coordination, visual-perceptual skills) gestalt
perception, spatial orientation, parts-whole relationships, visual memory, facial recognition, concept formation (both verbal and nonverbal), and executive functions. A recommended protocol would include the measures used in the
assessment of children with Nonverbal Learning Disabilities (Rourke, 1989). Particular attention should be given to demonstrated or potential compensatory strategies: for example, individuals with significant visual-spatial deficits
may translate the task or mediate their responses by means of verbal strategies or verbal guidance. Such strategies may be important for educational programming.
Communication Assessment
The communication assessment aims to obtain both quantitative and qualitative information regarding the various aspects of the child's communication skills. It should go beyond the testing of speech and formal language (e.g.,
articulation, vocabulary, sentence construction and comprehension), which are often areas of strength. The assessment should examine nonverbal forms of communication (e.g., gaze, gestures), nonliteral language (e.g., metaphor, irony,
absurdities, and humor), prosody of speech (melody, volume, stress and pitch), pragmatics (e.g., turn-taking, sensitivity to cues provided by the interlocutor, adherence to typical rules of conversation), and content, coherence, and
contingency of conversation; these areas are typically one of the major difficulties for individuals with AS. Particular attention should be given to perseveration on circumscribed topics and social reciprocity.
Psychiatric Examination
The psychiatric examination should include observations of the child during more and less structured periods: for example, while interacting with parents and while engaged in assessment by other members of the evaluation team. Specific
areas for observation and inquiry include the patient's patterns of special interest and leisure time, social and affective presentation, quality of attachment to family members, development of peer relationships and friendships,
capacities for self-awareness, perspective-taking and level of insight into social and behavioral problems, typical reactions in novel situations, and ability to intuit other person's feelings and infer other person's intentions and
beliefs. Problem behaviors that are likely to interfere with remedial programming should be noted (e.g., marked aggression). The patient's ability to understand ambiguous nonliteral communications (particularly teasing and sarcasm)
should be examined (as, often, misunderstandings of such communications may elicit aggressive behaviors). Other areas of observation involve the presence of obsessions or compulsions, depression, anxiety and panic attacks, and
coherence of hought.
Treatment and Intervention
(See also our Treatment and Intervention Guidelines)
As in autism, treatment of AS is essentially supportive and symptomatic. Special educational services are sometimes helpful, although there is, as yet, very little reported experience on the effectiveness of specific interventions.
Acquisition of basic skills in social interaction as well as in other areas of adaptive functioning should be encouraged. Supportive psychotherapy focused on problems of empathy, social difficulties, and depressive symptoms may be
helpful, although it is usually very difficult for individuals with AS to engage in more intensive, insight-oriented psychotherapy. Associated conditions, such as depression, may be effectively treated.
Despite the paucity of published information on intervention strategies and issues, a few guidelines may be offered based on informal observations made by experienced clinicians, intervention strategies used with individuals with
high-functioning autism, and Rourke's (1989) suggested interventions for individuals with Nonverbal Learning Disabilities syndrome.
Securing Services
The authorities who decide on entitlement to services are usually unaware of the extent and significance of the disabilities in AS. Proficient verbal skills, overall IQ usually within the normal range, and a solitary lifestyle often
mask outstanding deficiencies observed primarily in novel or otherwise socially demanding situations, thus decreasing the perception of the very salient needs for supportive intervention. Thus, active participation on the part of the
clinician, together with parents and possibly an advocate, to forcefully pursue the patient's eligibility for services is needed. It appears that, in the past, many individuals with AS were diagnosed as learning disabled with eccentric
features, a nonpsychiatric diagnostic label that is much less effective in securing services.
Learning
Skills, concepts, appropriate procedures, cognitive strategies, and so on, may be more effectively taught in an explicit and rote fashion using a parts-to-whole verbal instruction approach, where the verbal steps are in the correct
sequence for the behavior to be effective. Additional guidelines should be derived from the individual's neuropsychological profile of assets and deficits; specific intervention techniques should be similar to those usually employed
for many subtypes of learning disabilities, with an effort to circumvent the identified difficulties by means of compensatory strategies, usually of a verbal nature. If significant motor and visual-motor deficits are corroborated
during the evaluation, the individual should receive physical and occupational therapies. The latter should not only focus on traditional techniques designed to remediate motor deficits, but should also reflect an effort to integrate
these activities with learning of visual-spatial concepts, visual-spatial orientation, and body awareness.
Adaptive Functioning
The acquisition of self-sufficiency skills in all areas of functioning should be a priority in any plan of intervention. The tendency of individuals with AS to rely on rigid rules and routines can be used to foster positive habits and
enhance the person's quality of life and that of family members. The teaching approach should follow closely the guidelines set above (see Learning), and should be practiced routinely in naturally occurring situations and across
different settings in order to maximize generalization of acquired skills.
Maladaptive Behaviors
Specific problem-solving strategies, usually following a verbal rule, may be taught for handling the requirements of frequently occurring, troublesome situations (e.g., involving novelty, intense social demands, or frustration).
Training is usually necessary for recognizing situations as troublesome and for selecting the best available learned strategy to use in such situations.
Social and Communication Skills
These skills are possibly best taught by a communication specialist with an interest in pragmatics in speech. Alternatively, social training groups may be used if there are enough opportunities for individual contact with the
instructor and for the practicing of specific skills. Teaching may include the following:
Appropriate nonverbal behavior (e.g., the use of gaze for social interaction, monitoring and patterning of inflection of voice). This may involve imitative drills, working with a mirror, and so forth;
Verbal decoding of nonverbal behaviors of others;
Processing of visual information simultaneously with auditory information (in order to foster integration of competing stimuli and to facilitate the creation of the appropriate social context of the interaction);
Social awareness, perspective-taking skills, correct interpretation of ambiguous communications (e.g., nonliteral language) should also be cultivated and practiced.
Vocational Training
Often, adults with AS may fail to meet entry requirements for jobs in their area of training (e.g., college degree) or fail to maintain a job because of their poor interview skills, social disabilities, eccentricities, or anxiety
attacks. Having failed to secure skilled employment, sometimes these individuals may be helped by well-meaning friends or relatives to find a manual job. As a result of their typically very poor visual-motor skills they may once again
fail, leading to devastating emotional implications. It is important, therefore, that individuals with AS are trained for and placed in jobs for which they are not neuropsychologically impaired, and in which they will enjoy a certain
degree of support and shelter. It is also preferable that the job does not involve intensive social demands.
Self-Support
As individuals with AS are usually self-described as loners despite an often intense wish to make friends and have a more active social life, there is a need to facilitate social contact within the context of an activity-oriented group
(e.g., church communities, hobby clubs, and self-support groups). The little experience available with the latter suggests that individuals with AS enjoy the opportunity to meet others with similar problems and may develop
relationships around an activity or subject of shared interest.
Pharmacotherapy
Although little information about pharmacological interventions with individuals with AS is available, a conservative approach based on the evidence from autism should probably be adopted (McDougle, Price, and Volkmar, 1994). In
general, pharmacological interventions with young children are probably best avoided. Specific medication might be indicated if AS is accompanied by debilitating depressive symptoms, severe obsessions and compulsions, or a thought
disorder. It is important for parents to know that medications are prescribed for the treatment of specific symptoms, and not to treat the disorder as a whole.
New Developments in the Field
Although the current knowledge regarding the nature of AS and possible treatment interventions is still limited, there has been an impressive upsurge of research on this condition prompted by its formalization in DSM-IV. Two books on
AS, covering a variety of topics, will be available hopefully in late-1997. Several research projects are underway, and better instruments are currently being developed to improve assessment and diagnosis of the condition. More
importantly, awareness of AS is growing, and so is the general interest regarding the availability of services, appropriate educational placements and vocational training. The Learning Disabilities Association of America, in a
partnership with the Yale Child Study Center, will be disseminating this growing body of knowledge as it is developed. The importance of the participation of families affected by AS cannot be exaggerated. Families willing to
participate in ongoing research projects (involving the nature of AS, as well as service provision and treatment interventions) taking place at the Yale Child Study Center should read our project description.
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